Permission to Release/Withhold
Education Record Information
Complete Part I or Part II of this form and submit it in person to the Office of Admissions & Records by the
end of the third week of fall and spring semesters or the end of first week of the class for the summer and
winter terms.
Student Name: Student ID: M-
Address:
City, State, Zip:
Preferred Phone:
Part I- Authorization to Withhold Directory Information [Opt Out]
The following is considered directory information at Montgomery College and will be made available to the general public
unless the student notifies the Office of Admissions & Records in writing as specified in the instructions above:
Student’s name; major field of study including current classification, year, credit load, and number of academic credits
earned toward degree; dates of attendance; degrees and awards received (type of degree and date granted); and
participation in officially recognized activities and sports, photograph, weight, and height of members of athletic teams.
The following information will not be disclosed, but may be verified: Address; telephone listing; and date of birth.
Under FERPA’s provisions, you have the right to withhold disclosure of directory information. Montgomery College will
honor your request to withhold directory information.
Please consider carefully the consequences of any decision to withhold directory information. Should you decide not to
release this information; any requests for such information from the College will be refused.
This authorization is valid until a written request to rescind is received by the Office of Admissions and Records.
I hereby request Montgomery College not to release any directory information from my academic records. I have read
the above paragraph and understand the consequences of my action.
Student Signature Date
Listed Phone Number is:
Home Work
Cell
AEM 6/21/12
Part II- Authorization to Disclose Academic Information to Third Parties
Under FERPA, Montgomery College is permitted to disclose information from your education records to your parents
without your consent, if your parents (or one of your parents) claim you as a dependent for federal tax purposes. Your
parents can present their photo identification and most recent Federal Tax form 1040 for disclosure. To provide the
same level of access to any other third party, please list the full, legal name of each person who you allow to access
your student records:
Student Signature Date
Name(s):
**** NOTE: If Part I is signed, you may not fill out Part II.****
